Psychotherapy Bulletin

Psychotherapy Bulletin

The Sign of Good Work in Psychotherapy

Deaf Practices and Customs

The clock reads 1:55 p.m.; it is time for your next session. You go to the waiting room and there sits your new client, head down in their phone, as is common for clients waiting to see you. As you approach, you start introducing yourself; however, the client does not look up. You raise your voice and try again. No response. Finally, you place yourself in front of the client and clear your throat. The client does not respond for a second, and then glances up and gives you a look of surprise. The client starts to sign to you. Suddenly, your mind racing, you realize: Your client is Deaf. You immediately think, “Where should I go from here?”

Sometimes it has not been communicated to the therapist that a client is Deaf and, as result, the therapist is unprepared. Other times the therapist simply does not know how to proceed. This narrative is designed to provide clinicians who may not have worked with Deaf clients previously an introduction to Deaf culture and resources for better serving members of the Deaf community.

Basic Considerations

What does it mean to be Deaf? An audiological definition means the lack of hearing or a hearing impairment. Viewing it through a medical model, deafness is the inability to hear; a disability. Still another model used to view Deaf people is a cultural model. The Deaf culture model uses an uppercase D to denote it as a formal culture. The medical model uses a lowercase d to denote they are talking about a disability. The cultural model argues that being Deaf stands alone as its own culture, with its own language, practices, customs, traditions, and community (Lane, Hoffmeister, & Bahan, 1996). Which model should you use? The answer is simple—whichever one with which the client identifies. Often, hearing psychotherapists think they know what is best and either assume Deaf clients see themselves as impaired or see themselves as culturally different, instead of asking about the individual client’s identity (Lane et al., 1996). This may seem obvious, but it is one of the most overlooked aspects when working with Deaf individuals. Identity matters and, to members of the Deaf community, Deaf culture may be a salient identity. As with any client, neither identity nor cultural practice should be assumed (Gutman, 2002).

Hearing people often assume all Deaf people are able to lip read and know sign language. However, this is not true; each Deaf individual is going to be different. Sensitivity starts with knowing a little bit about Deaf culture. One can read about the culture, and there are several books (listed below) with which to start. However, the best way to learn about Deaf culture is to experience it. Most cities have resources and a welcoming Deaf community with which hearing psychotherapists can become involved. Consider taking sign language classes where, in addition to the language, you can often learn about culture. Continuing education classes and community classes specializing in working with Deaf clients are also great ways to expand your knowledge base. Look up professionals in your area who work with Deaf clients, take some time to get to know them (as uninformed referrals could put the client in a worse situation), and use them.

When learning about Deaf culture, you will come across a number of “do” and “do not’s”. First, do not raise your voice when a member of the Deaf community does not understand what you say. Deaf people tend to be visually oriented, and when you raise your voice, your facial expressions change. It is a sign of rudeness to raise your voice (Leigh, 2010). Another common problem is deciding where to look when talking to a Deaf individual. Make eye contact. Do not look down or away when speaking, even with another person in the room. Look directly at the recipient of your speech, even if that person is not looking directly at you (for example, when an interpreter is being used). Part of becoming sensitive is asking clients how they would like to communicate. Not everyone uses sign, and it is essential to find out how your client prefers to communicate. This is the most important aspect of working with Deaf individuals: Each person is different, and the importance of using the most comfortable form of communication is key to a successful interaction.

Communicating Ethically and Effectively

Although those with limited or no experience with working with Deaf clients may consider referring to a provider who is more experienced, referral is not always an option, and may not be preferred in a given situation for a variety of reasons. Remember: Asking about your client’s preferred mode of communication is imperative. Clinicians with limited fluency in sign language are likely aware that, as with any language, it must be practiced consistently to be mastered. It certainly helps to know some sign language, but if you are not fluent (or not fluent in the client’s language of choice), do not rely on sign based skills in a therapy session. Use an interpreter, if doing so is possible and aligns with the client’s needs and wishes.

Choosing an interpreter

Finding an interpreter who is skilled in the client’s particular language of choice is crucial to understanding the client. Do not let family, significant others, or friends interpret for your client. Set boundaries and empower the client to be in charge of the therapy and its content. Allowing a non-certified interpreter to interpret is both unethical and potentially harmful to the relationship and the client’s growth while under your care.

Working with an interpreter

What do you do when the interpreter arrives? Sit down with the interpreter and talk about how the session will go, what communication will look like, and what happens if there is a breakdown in communication. And, what I believe to be paramount, talk about privacy and subjects that might come up in therapy and how to handle them. Remember, an interpreter is there to facilitate the language difference between you and your client—not function as a therapist or educate you in Deaf practices. One pragmatic issue to consider is room setup. Having the interpreter slightly behind the therapist and to the side allows the Deaf individual to see both parties, and allows you to connect with the client more directly, conducting therapy as you typically would. Another common concern is who pays for the interpreter. The short answer is: It is not always clear. However, the type of practice, service being provided, and referral source may impact funding. In private practice expenses may be covered by an insurance company, paid by the Deaf individual, or come out of the therapist’s fees. This is a real problem and a limitation to seeing Deaf clients, and financial matters should be addressed proactively to prevent misunderstanding.

Issues of Competency

Providing psychotherapy services

Issues of competency may arise when inexperienced psychotherapists work with members of the Deaf community. Under such circumstances, the psychotherapist should seek supervision from a clinician specially trained in Deaf psychological processes. A good starting point is the National Directory of Deaf Trained Professionals (Gallaudet University, 2016; available on the Gallaudet University website:, which provides information regarding those who specialize in providing help to Deaf individuals. Another suggestion is to look up the Deaf-specific community resources in your area.

Providing assessment services

When performing psychological evaluations with Deaf individuals, providers need to understand underlying assessment principles, and how to apply them to Deaf individuals. Merely translating an assessment instrument does not make it valid to administer to a new culture (Brice, 2002). Many assessments are designed to answer questions about knowledge, behavior, or emotion. The types of data used may vary with the measure, but typical assessments are based on hearing norms (Fellinger, Holzinger & Pollard, 2012). Deaf individuals may differ from hearing individuals in terms of English-based reading skills, short-term memory, or in other nuanced ways that could significantly impact results, leading to an inaccurate representation of level of functioning.

Getting Started

If you are interested in understanding more about Deaf culture and working more effectively with Deaf clients in psychotherapy, a number of excellent books may help you get started: Deaf Mental Health Care edited by Neil Glickman (2013), Psychotherapy with Deaf Clients from Diverse Groups edited by Irene Leigh (2010), Ethics in Mental Health and Deafness edited by Virginia Gutman (2002), Journey into a Deaf World by Lane, Hoffmeister, and Bahan (1996). Next, I recommend you engage with the Deaf community. A quick Internet search will take you to Deaf community resources in your area. An excellent resource to know and use is the website from the National Association of the Deaf (n.d.; Here you will find a list of Deaf agencies and services. Lastly, if you find this subject fascinating and want to pursue this field, Gallaudet University (2016) has the only program of its kind with a doctorate program in clinical psychology, specializing in working with Deaf and Hard of Hearing individuals.

Challenges and Rewards

Obviously there will be challenges. Sign language may not come as easily as other languages to many; it is a total communication language, using the entire body rather than simply speaking words. It requires one to practice and engage in communication that may not be intuitive to grasp (Brice, Leigh, Sheridan, & Smith, 2013). Personally, I found learning sign language to be one of the most difficult challenges of my life. When I become discouraged, however, I remember a favorite sign language teacher joking about starting to get the hang of American Sign Language after some nine years of practice. And fluency in the mechanics of communication is not the only obstacle. As noted by Brice et al. (2013), whenever two cultures sit down and try to come together, challenges will occur. This tension exists when I, as a hearing therapist, am working with a Deaf client. Most Deaf individuals expect to work with a hearing therapist, but long for an opportunity to work with a Deaf therapist (Steinberg, Loew, & Sullivan, 2010). We all want our therapists to be similar to us, to understand us, and to relate to our struggles on some level. It is the same for my clients when they think I am too different from them to be of service. With Deaf clients, I try to validate their concerns while exploring with them ways to work together effectively to accomplish their therapeutic goals.

With all that has been mentioned thus far, I do not mean to frighten you away from working with Deaf individuals. Quite the opposite, actually: I hope to encourage clinicians who are not engaged with the Deaf community to consider becoming more involved. Seeing Deaf clients “light up” when they can sign directly to their therapists for the first time creates feelings I will never forget. The impact that being understood, linguistically and culturally, has on a client is difficult to quantify. As a therapist, connecting with your clients on a deeper level and assisting them in understanding more about themselves through the lens of therapy is rewarding under any circumstances; when it happens for the first time with a Deaf client, the feeling is amplified. These are experiences you cannot get from reading a book. Getting to know people and experiencing their culture will build a much stronger understanding of the community. For me, one of the most gratifying moments in my professional training was being honored and integrated into the Deaf community through being given a sign name. This cultural ritual communicated acceptance and respect, and it warmed my heart to be welcomed into a small part of Deaf culture. For the record, my sign name is Bowtie.


This overview is by no means comprehensive, but I hope it has given you a glimpse into some of the rewards, challenges, and pragmatic considerations in psychotherapy work with members of the Deaf community. I encourage you to seek more resources and further your knowledge. The only way to understand is to learn, and the only way to learn is to invest time and interest. I wish you luck in your journey.

Cite This Article

Shelenhamer, G. (2016). The sign of good work in psychotherapy: Deaf practices and customs. Psychotherapy Bulletin, 51(2), 50-53.


Brice, P. J., (2002). Ethical issues in working with Deaf children, adolescents, and their families. In V. Gutman (Ed.), Ethics in mental health and deafness (pp. 52-67). Washington, DC: Gallaudet University Press.

Brice, P. J., Leigh, I. W., Sheridan, M., & Smith, K. (2013). Training of mental health professionals: Yesterday, today, tomorrow. In N. S. Glickman (Ed.), Deaf mental health care (pp. 298-322). New York, NY: Routledge/Taylor & Francis.

Fellinger, J., Holzinger, D., & Pollard, R. (2012). Mental health of Deaf people. The Lancet, 379(9820), 1037-44. doi: 10.1016/S0140-6736(11)61143-4

Gallaudet University. (2016). Mental health services for people who are Deaf or Hard of Hearing. Retrieved from

Gallaudet University. (2016). Ph.D. in clinical psychology. Retrieved from http://www.gallaudet. edu/psychology/graduate-programs/phd-clinical-psychology.html

Glickman, N. S. (Ed.) (2013). Deaf mental health care. New York, NY: Routledge/Taylor & Francis.

Gutman, V. (Ed.). (2002). Ethics in mental health and Deafness. Washington, DC: Gallaudet University Press.

Gutman, V. (2002). Ethics in mental health and deafness: Implications for practitioners in the “small world.” In V. Gutman (Ed.), Ethics in mental health and Deafness (pp. 11-37). Washington, DC: Gallaudet University Press.

Lane, H. L., Hoffmeister, R., & Bahan, B. J. (1996). A journey into the Deaf-world. San Diego, CA: Dawn Sign Press.

Leigh, I. W. (Ed.). (2010). Psychotherapy with Deaf clients from diverse groups (2nd ed.). Washington, DC: Gallaudet University Press.

National Association of the Deaf. (n.d.). Retrieved from

Steinberg, A. G., Loew, R. C., & Sullivan, V. J. (2010). The diversity of consumer knowledge, attitudes, beliefs, and experiences. In I. W. Leigh (Ed.), Psychotherapy with Deaf clients from diverse groups (pp. 18-38). Washington, DC: Gallaudet University Press.


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